A nurse is preparing to clean a client's dentures. Which of the following actions should the nurse plan to take?

ANSWERED:

Day 1:

• Abdomen soft, nondistended.
• Ileostomy present. Stoma is red.
• Stoma draining brown liquid stool.
• Client will not look at stoma
• Client states they are not interested in learning about stoma care.

Day 2:

• Ileostomy pouch changed. Skin surrounding stoma is reddened and has small open areas.
• Stoma with small amount of bleeding noted during cleaning.

Rationale:

Findings requiring intervention

Client will not look at stoma: This indicates potential emotional distress, denial, or difficulty adjusting to the ileostomy. The nurse should address these concerns by providing emotional support and encouraging gradual acceptance of the stoma through education and therapeutic communication.

Client states they are not interested in learning about stoma care: A lack of interest in learning stoma care poses a barrier to self-care and independence. The nurse should explore the client’s feelings, provide gentle encouragement, and offer step-by-step guidance to build their confidence.

Skin surrounding stoma reddened and has small open areas: Redness and open areas suggest irritation or breakdown of peristomal skin, likely due to improper pouch application or leakage. The nurse should assess the fit of the ileostomy pouch, recommend barrier creams, and consult a wound care specialist if needed.

Findings not requiring intervention

Abdomen soft, nondistended: This finding is normal and does not indicate any issues requiring intervention.

Stoma is red: A healthy stoma is typically moist, red, and similar in appearance to the inside of the mouth. This finding is expected.

Stoma draining brown liquid stool: Brown liquid stool is a normal output for an ileostomy and does not require intervention.

Stoma with small amount of bleeding noted during cleaning: Minimal bleeding from the stoma is common during cleaning or manipulation, especially early postoperatively. This is generally not a concern unless the bleeding is excessive or persistent.

A. Case managers are responsible for coordinating care, including arranging for services such as home health care, ensuring continuity of care after discharge.

B. Writing prescriptions is outside the scope of case management and is a responsibility of licensed providers such as physicians or nurse practitioners.

C. Performing nursing tasks, such as dressing changes, is a role carried out by bedside nurses or home health care nurses, not case managers.

D. Providing education about medications is typically the responsibility of bedside nurses, as they are more directly involved in client education during care.